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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# RVICE REQUEST y <br /> 191 <br /> TpUa,4' < q <br /> OWNER/OPERATOR <br /> C�y Q Q CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 5 Street Number Direction o y reef Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (If Differ` ( <br /> ent from Site Address) <br /> 14 / <br /> v " Street Number Street Name <br /> CITY � � $TATE Zip 5 <br /> PHH0NNEE#j1/ EXT, APN# LAND USE APPLICATION# (� <br /> PHONE fit EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Sanim <br /> /M CHECK if BILLING ADDRESS <br /> BUSINESS NAME -n,\/� V\- �- PHONE# EXT. <br /> HOME Or MAILING ADDRESS /��/� ,/} �w FAX# ) <br /> CITY /j A I`fhlf^ 7J1�1 C�/ STATE CA <br /> ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, " <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TATE an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT iS not the BILLING PARTY,proof of authorization to sign is required 7'it[e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is p 'ded to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: rl •� <br /> COMMENTS: � F� <br /> h�Mo.�V�NCO o1,9 <br /> O�t:Aq�NT�N�y <br /> MFN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: /c EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PI L00-� <br /> Fee Amount Amount Pa Payment Date <br /> r <br /> Payment Type Invoice# Ch ck# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />